text:
Kristine Brennan, Senior Associate Editor
Can Corneal Inlays Work for Your Practice?
Surgeons discuss the pros and cons of this new approach to refractive correction.
Corneal inlays are intended to be simple, lifelong interventions to end or reduce spectacle dependence—and its accompanying inconvenience—for presbyopes, who, according to one 2008 study, are projected to number approximately 1.37 billion globally by 2020.1 Speaking to surgeons who are in the know, however, you learn that their colleagues have been slow to adopt this new technology, as demonstrated by the recent shuttering of ReVision Optics, maker of the now-discontinued Raindrop inlay. Potential roadblocks to success with inlays include variations in individual wound healing postoperatively and tear-film difficulties, as well as potential unwanted side effects from postop topical steroids.2
Here, surgeons who offer corneal inlays—both the Kamra and the defunct Raindrop—weigh in on who's getting them, the mechanics of implanting them, their pros and cons, and where they think the future of inlays is headed.
Slow Adoption
John A. Hovanesian, MD, clinical instructor at the Jules Stein Eye Institute, University of California, Los Angeles, and in practice at Harvard Eye Associates in Laguna Hills, believes that incorporating corneal inlays into refractive practice is well worth the effort, but notes that they haven't penetrated the market deeply. "I think we surgeons as a population have been pretty hesitant to take up inlays. There is a learning curve for us, and a phase of patient education that we need to go through," he says. He says ReVision Optics' closing and discontinuation of the Raindrop was a result of several factors. "The technology itself was a good performer," he says. "It was good enough for me to implant two inlays in close, personal friends, both of whom were quite happy. Personally, I believe the slow adoption of the Raindrop inlay was attributable to the 'competition' of great results with LASIK and premium IOLs. While neither procedure is ideally suited to the emmetropic presbyope who was a candidate for Raindrop, both have received wide public acceptance and adoption by surgeons. In addition, achieving a quiet eye with the Raindrop inlay required more follow-up and diligence after surgery than other refractive procedures."
Currently, ophthalmology has been slow to dive into inlays. It's possible that, as Dr. Hovanesian notes, surgeons aren't interested in cresting a new learning curve. In terms of safety and efficacy, in the absence of a lot of large-scale, postmarket data, U.S. ophthalmologists have the FDA trials to go on for the Kamra (AcuFocus; Irvine, California) and the discontinued Raindrop. The FDA's summary
Because it is made of dark polyvinylidene fluoride, the Kamra small-aperture inlay may be visible in eyes with light-colored irises.
report on the Kamra shows that of the 508 operated eyes studied, 44 (8.7 percent) had had the inlay removed at 36 months, with unacceptable hyperopic shift (25/44) cited as the most frequent cause. (For the subgroup of 166 eyes implanted per the instructions currently in force, seven had the Kamra removed.)3 For the Raindrop, 27 of 373 operated eyes (7.2 percent) studied in the FDA trial had that inlay removed at 36 months. Haze and patient dissatisfaction with visual outcome after three months postop were tied as the top reasons for explantation at 10 cases out of 27 apiece.4
"We know they can work, because there are practices that are really succeeding with them," Dr. Hovanesian says. "We refractive surgeons need to try and make this a successful addition to our surgical armamentarium."
Who's Getting Them?
Surgeons say that, in the right patients, the inlays can work well.
Dr. Hovanesian says that inlays are aimed at emmetropic presbyopes, who are a tricky group to satisfy. "These patients have low refractive error but desire freedom from eyeglasses for reading. Such patients tend to be in their late 40s to 50s," he says. "They don't have significant cataract yet and they're highly motivated to do something. They have heard of LASIK; most of them have heard of monovision, but many have a bias against it. A traditional approach is unlikely to apply very well to them, making inlays a good fit."
Jeffery J. Machat, MD, FRCSC, DABO, medical director of Nvision Eye Centers in Toronto and San Francisco, became part of the inlay market in August 2012, when he decided to get a Kamra implanted in his own eye. "There's sort of a moment that hits you where all of a sudden, you feel your age," he says. "For me, it was the size of the font on my iPhone—and my teenage daughter who tormented me about it for an entire day. I said to myself, 'Okay, that's it. I need to do something.' "
A refractive surgeon with 27 years of experience at the time, Dr. Machat sought a treatment with a high safety profile. "A corneal inlay made a lot of sense to me," he recalls. At the ASCRS meeting that year, he listened to John A. Vukich, MD, present early FDA data on the Kamra. Dr. Vukich closed with a case presentation, in which he revealed that he was in fact the subject. Dr. Machat recalls that he was convinced to proceed after questioning Dr. Vukich post presentation. "I went ahead and had it done myself with Dr. Minoru Tomita in Japan, and I was really thrilled. I had a very fast visual recovery. The very next day I was already J1, and three days later I was operating," he says.
Shortly after the procedure, Dr. Machat integrated the Kamra into his Toronto practice. "We got approval [from Health Canada] in September 2012. At that time, they were still doing thick corneal flaps, not pockets, for insertion of the inlay. But we rapidly learned that a pocket deeper in the cornea was a better approach surgically and we got far better results, so there was definitely a learning curve," he says.
The current version of the Kamra inlay is a dark polyvinylidene fluoride ring etched with perforations, 6 µm thick and 3.8 mm in diameter. Its central aperture is 1.6 mm, and it is placed over the first Purkinje image when implanted into a stromal pocket 200 to 250 µm deep. Long-term data suggest that the Kamra results in notably improved monocular and binocular uncorrected near and intermediate vision, with a small loss of monocular and binocular uncorrected distance visual acuity. In a study with five-year follow-up, mean UNVA at 60 months was improved from J7/J8 preoperatively to J3 ±2 lines. Of 32 patients, two required recentration of the inlay at six months; one Kamra was explanted due to unsatisfactory hyperopic shift; one patient had epithelial ingrowth in the early postop period.5 Notably, the study patients got their inlays from 2006 to 2007, and so were implanted with an earlier version of the Kamra that was 10 µm thick, etched with fewer holes and that allowed more unfocused light onto the retina.
John A. Vukich, MD, associate clinical professor of ophthalmology at the University of Wisconsin Madison School of Medicine and in private practice at Davis Duehr Dean Eye Care in Madison—and the impetus for Dr. Machat's decision to get his own inlay—says that most of his inlay patients present as prospective LASIK patients. "The most common inlay patients that we treat are individuals who are interested in LASIK to begin with, and then this creates a value-added option," he explains. "Patients who are looking for LASIK in the presbyopic range are generally either higher myopes (-4, -5, -6 D) or they are hyperopic. They understand that they have to wear reading glasses over their contact lenses if they're hyperopic; or if they're myopic above -4 D, they can't take their glasses off and read comfortably. These individuals all understand the inconvenience of presbyopia, and they also understand that being able to have that extended depth of focus and freedom from reading glasses—or a least a significantly diminished need for them—is a real benefit," says Dr. Vukich, who offers the Kamra inlay to his patients.
Dr. Hovanesian notes that a patient's preop refraction is important when placing an inlay. "I tend to prefer the Kamra for patients who are slightly myopic," he says. "As we know, the ideal patient for the Kamra is about -0.75 D. For the Raindrop, the ideal patient was more like a +0.75 D.
"Another thing to consider is that there is a little cosmetic concern with the Kamra, particularly for people with lighter-colored eyes, because it can be visible to the patient," continues Dr. Hovanesian. "I've not actually had anyone who's received it and been unhappy with it, regardless of eye color, but I think it's a conversation worth having with patients." Of the 44 explanted Kamras in the FDA pivotal study cohort, two were removed for cosmesis.3
When he combines inlays with LASIK, Dr. Hovanesian notes it's important to adjust the refractive target. "In those who are more myopic it's best to undercorrect the nondominant eye with the intention of later putting in a Kamra," he explains.
Dr. Hovanesian looks forward to the FDA approval of the Flexivue Microlens (Presbia Coöperatief U.A.; Irvine, California), a refractive inlay 3 mm in diameter made of clear UV-blocking copolymer. The central zone has zero refractive power and a 0.15-mm hole. Its peripheral zone comes with add powers ranging from +1.25 to +3.5 D in 0.25-D increments. The Microlens varies in thickness from 15 to 20 µm, depending on add power. "It's still undergoing FDA trials. But so far, the data look good and it should offer promise as another valuable entrant into this market," he says. The multicenter Phase III trial will follow approximately 412 patients between 45 and 60 years old implanted with the Microlens. The study is expected to wrap up in early 2019 (ClinicalTrials.gov Identifier: NCT02110472).
In a study of 47 emmetropic presbyopes with the Microlens inserted in a femtosecond laser-created corneal pocket 280 µm deep, no complications occurred over the 12-month follow-up period, and 75 percent of the patients achieved uncorrected near visual acuity of 20/32 or better in the operated eye. The operated eyes' mean uncorrected distance acuity dropped from 20/20 preop to 20/50 (p<0.001), while mean binocular UDVA did not change significantly (p=0.516).6
"I've done the Microlens in Canada," says Dr. Machat. He observes that patients could start with one Flexivue lens power and then replace it with a higher one as presbyopia progresses, but also that patients getting inlays generally won't do this. "We have found in our very limited experience that patients do not want to put in an inlay and then come back in two or three years for another one. From a patient's-reality perspective, most people will just put in a +2.25 D Microlens and that's it. Patients were losing more distance than we expected, but getting good reading," he says.
Lifelong Implant
"I'm excited about corneal inlays because I think of them as a lifelong procedure for patients. With the Kamra, we're altering the cornea to allow depth of focus, and that change in shape lasts the rest of the patient's life, even after a cataract surgery," says Dr. Hovanesian. "We have in fact done cataract surgery on patients who have previously undergone Kamra as part of the FDA study prior to approval, and those patients have done very well."
Dr. Machat concurs that corneal inlays can last a lifetime without complicating future ophthalmic interventions. "The Kamra inlay and the Raindrop inlay continue to work until someone develops a cataract," he says. "I'm going to leave my corneal inlay in once I develop lenticular opacities, and just put in a monofocal IOL and target -1 D for reading. I won't need to put a multifocal in my left eye; I won't need to remove it. I won't need to do anything," he says.
Dr. Machat
A surgeon opens the pocket in preparation for sliding in the Kamra presbyopic intracorneal inlay.
will do LASIK and inlays on the same day or break up the procedure, depending on the clinical indications. "LASIK takes about six minutes; a Kamra inlay, once you get experienced, takes about six minutes," he says. "But if someone has a high prescription or a complex prescription, or a lot of preoperative dry-eye concerns, then I'll break up the procedure because I want to make sure that I have achieved my target refraction. Let's say they're +3 D and I'm targeting -1 D, which would be about the maximum I would do on a cornea that's flat and not dry. Or let's say they're -8 D. I want to wait and make sure that they don't regress. In those cases, I'll do LASIK, wait a month, refract them to make sure I've hit my target refraction, and then I'll go ahead and insert the inlay. But if there's no clinical reason not to, then I do it all the same day.
"I'll do LASIK for about 80 percent of my corneal inlays," Dr. Machat continues. "So this has increased my LASIK practice. We often have patients who are early presbyopes and we just leave them a little bit undercorrected; that'll put off their need for readers for about five years, and then they'll come back as soon as they need a corneal inlay. All of a sudden, that inlay takes the -0.75 D and gives them 3 D of accommodative range, so they're thrilled. We've done them in pseudophakes; we've done them in post-LASIK patients and post-PRK patients, as well as in virgin corneas. It's definitely worked well for us."
"In terms of this being a treatment for life, our experience has been that you can certainly do a cataract surgery with these inlays in place, and it really doesn't get in the way," concurs Dr. Vukich, who also says that the majority of his Kamra patients need to be brought to plano or -0.5 to -0.75 D of sphere correction in their nondominant eye to prepare for the inlay.
The Kamra obstructs the view of a small portion of the retina. The FDA summary report on the Kamra warns that medical laser treatments for certain eye conditions may warrant extra caution or even removal of the inlay.3 "Retinal surgeons initially felt like there might be some obstructed view, but that hasn't turned out to be the case," says Dr. Vukich. "You can see around them quite easily."
Dr. Hovanesian doesn't think they pose much of a visibility problem in the event of future retinal evaluation and treatment, either. "Some retinal specialists are concerned about this with the Kamra, but if you have a pupil that dilates reasonably well then it's really not an issue to see around it," he says. "It's like looking around a tiny corneal scar: You still see around it if the cornea is clear outside the area of the inlay."
Challenges with Inlays
Some surgeons think the slow adoption rate of corneal inlays among surgeons may just be explained by their relative novelty on the refractive scene.
"The challenge with inlays is a lack of familiarity on the part of the general public," says Dr. Hovanesian. "When we started doing LASIK years ago, it was perceived as a cutting-edge, possibly risky new procedure. People had questions about safety; they had questions about long-term stability of results. Today, 20 years later, everyone has friends who've been through LASIK and who've had positive things to say about it. Inlays are like LASIK was 20 years ago. We have to help patients understand what they are, how they work, and what their benefits are."
"It's not unlike the early days of LASIK surgery," agrees Dr. Vukich. "It took a couple of years before patients really understood and knew someone who'd had it done," he says. "It's true that we're not seeing huge numbers at this point, but it is quietly and steadily gaining momentum."
Dr. Machat introduces a corneal inlay as an improvement on LASIK alone. "We present it to patients as an upgrade, he says. "If you get LASIK, you're going to get distance vision but you're going to need reading glasses. Patients ask if there are any other options. We like the corneal inlay because patients retain binocular distance vision. If someone has -1 D monovision, that monovision will only
The Raindrop was a nonrefractive inlay made of clear hydrogel. It approximated the cornea's refractive index.
last so long, whereas with an inlay it will last for decades. It's resistant to the progression of presbyopia.
"The word of mouth has been quite dramatic," Dr. Machat continues. "If you think of myopes, one in four of their friends are myopic: When you think of presbyopes, 100 percent of their friends are presbyopic. Having presbyopic solutions that go beyond multifocal IOLs is a vital part of any refractive practice."
Dr. Hovanesian says that his staff and co-managing optometrists help get the word out about corneal inlays. "We have folks in the practice who do that very well, along with some docs outside. Just like there was with LASIK, there's a bit of education mode that the co-managing doctors have to engage in," he says.
"Train your staff," urges Dr. Machat. "Get them on board. Really make sure that they understand, because this is a new but highly effective treatment. Also, have an age-appropriate patient consultant. We hired patient consultants who were in their 50s, because someone who's in their 50s doesn't want to talk to a 24-year-old. They want to talk to someone who can actually relate to them and understand presbyopia. I gave a patient consultant on my staff LASIK because she was a moderately high myope, and I inserted a Kamra inlay. She was then able to really talk to our patients about it."
In addition to educating patients about the benefits of corneal inlays, setting their expectations is also key. "You have to tell patients ahead of time that vision does improve, but it may take a couple of weeks, and sometimes, it may take even a little longer before they get the full effect," stresses Dr. Vukich. "I simply tell patients, 'It's going to take a little while, so if you're not getting the full effect, we anticipate that. It takes awhile for things to settle down and for the ocular surface to optimize and for the healing to take place,'" he says. "Patients need to know what to expect."
Fine-tune Your Follow-up
"There is clearly a period of postoperative care that is necessary with inlays," Dr. Vukich continues. "These patients are treated with steroids, typically for up to a month or longer after the procedure on a tapering schedule. Typically, we see them at one day, one week, and one month, but of course we'd adjust that as necessary."
Dr. Hovanesian says that you may need to train your staff to do a little more handholding for postoperative inlay patients than for post-LASIK patients. "There's a little bit of healing time. There's a little bit more follow-up care," he notes. He adds that some inlay patients may need a reminder of their preop vision to appreciate how far they've come postoperatively. "Some patients get an inlay, and six months later they kind of forget what their preop vision was like. One thing that we actually learned to do from the FDA study—and I recommend this to all surgeons—is to take a little handheld 8.5 x 11-inch reading card, and have the patient read the smallest print they can on it. Have them sign it, and put it in their chart. Later, if they're wondering if their inlay is doing anything for them, you can pull that card out and show them. They can always read much better after the procedure than before and sometimes they're amazed at what a difference it's made. They simply forgot how bad their previous reading vision was. Sometimes you just have to remind patients of what you've done for them."
Having experienced the Kamra as both a patient and a surgeon affords Dr. Machat insight when answering patients' questions about potential near-vision difficulty under mesopic conditions. "All presbyopes have trouble when it's dark," he says, "but it's not like the inlay makes your vision much darker, so that you suddenly have to use a light when you didn't previously. But there is also retinal adaptation occurring. It's very interesting." Dr. Machat says he experienced this adaptation firsthand as his vision in low-light conditions steadily improved during the postoperative months. Dr. Machat's clinical director, Sondra Black, OD, reported the same thing after her Kamra procedure, he says. "She found that her vision under low light improved over an entire year. When you talk to scientists like Jay Pepose, he says that this is exactly what occurs. I got to live it. I was very surprised by it and it didn't make sense to me, but it's true," he says.
For all the potential benefits corneal inlays can confer, the procedure also confers the risks that come with putting a foreign body into the eye. "There is no such thing as a surgery that has a zero complication rate. Anytime we do something, there's the possibility of an unexpected or untoward outcome," Dr. Vukich notes of his experience with the Kamra. "One of the things we have seen is epithelial implantation: At the time the implant was placed, a nest of epithelial cells was brought in with the implant. We believe it occurs in less than a fraction of 1 percent of patients, and it's easily fixed. We can simply rinse out the epithelial cells. We've also had one patient in which the implant was slightly irregular because of a micro-fold. That was early on in my experience, so there is a bit of a learning curve in terms of how to place the implant quickly, atraumatically and in the location that you're looking for," he says, "but inlay surgery is well within the skill set of any anterior segment surgeon."
One potential plus of corneal inlays is that they are strictly additive and removable. "There's no such thing as a reversible operation, but the inlay is clearly removable. So to the extent that we can restore the native architecture—with the exception of the incision we've made—by removing the implant, I think people find that reassuring," says Dr. Vukich, who reports that he has explanted one Kamra. Although patients who have their refraction set for anisometropia in anticipation of an inlay are left in that state if the inlay later comes out, Dr. Vukich says that this has not been problematic over the course of his experience with the Kamra. "If and when an implant needs to be removed, the opportunity for enhancement to bring patients to emmetropia exists and we'll tell them we can do that, but we really have not had anyone ask for it," he says, adding that patients enjoy the near component created by LASIK in the nondominant eye despite a slight loss of distance visual acuity.
Check Your Technology
Dr. Machat notes that you need the right tools to offer corneal inlays. "You have to keep a really high-quality femtosecond laser with a really tight raster pattern," he says. "So that was one of the advantages of using the Raindrop: You just needed to make a flap that was one-third of the central corneal thickness, so you didn't need pocket software," he says.
Although he acknowledges that obtaining the requisite technology for corneal inlays might be prohibitively costly for surgeons not currently offering LASIK, Dr. Vukich says that investment is minimal for those already offering it. "For a surgeon who is already doing LASIK surgery, there is almost no startup cost to this," he says.
Dr. Machat says he purchased the AcuTarget HD, the forerunner of the HD Analyzer (Visiometrics; Costa Mesa, California) when he started offering the Kamra. The costly imager is pretty much a must-buy for Kamra surgeons, a fact that may have discouraged some from getting involved with Kamra. Dr. Machat also suspects that the system's name at that time led to some surgeons declining to adopt inlays because of a mistaken belief that the AcuTarget was only good for inlay centration. "What they're not realizing is that I use it for Kamra only 5 percent of the time; 95 percent of the time, I use it for refractive lens exchange, dry eye and other procedures," he says.
Dr. Vukich also says that the HD Analyzer is a great help with inlays, but that it its use isn't limited to that area of practice. "I think that in the setting of using inlays it's quite valuable to have, but quite frankly, we use it far more widely than just for implanting inlays," he says. REVIEW
Dr. Hovanesian was a consultant for ReVision Optics and consults for AcuFocus. Dr. Machat is on the medical advisory board for AcuFocus and is a consultant for Viseometrics. Dr. Vukich is a consultant for AcuFocus, and was an investigator and part of the FDA regulatory team.
1. Holden BA, Fricke JR, Ho SM, et al. Global vision impairment due to uncorrected presbyopia. Arch Ophthalmol 2008;126:1731-39.
2. Moarefi MA, Bafna S, Wiley W. A review of presbyopia treatment with corneal inlays. Ophthalmol Ther 2017;6:55-65.
3. Food and Drug Administration. FDA summary of safety and effectiveness data (SSED). PMA P120023. https://www.accessdata.fda.gov/cdrh_docs/pdf12/P120023B.pdf. Retrieved 1/17/2018.
5. Dexl AK, Jell G, Strohmaier C, et al. Long-term outcomes after monocular corneal inlay implantation for the surgical compensation of presbyopia. J Cataract Refract Surg 2015;41:3:566–75.
6. Limnopoulu AN, Bouzoukis DI, Kymionis GD, et al. Visual outcomes and safety of a refractive corneal inlay for presbyopia using a femtosecond laser. J Refract Surg 2013;29:1:12-18.
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text:
require "httpi"

module Savon
  module WSDL

    # = Savon::WSDL::Request
    #
    # Executes WSDL requests.
    class Request

      # Expects an <tt>HTTPI::Request</tt> to execute a WSDL request
      # and returns the response.
      def self.execute(request)
        new(request).response
      end

      # Expects an <tt>HTTPI::Request</tt>.
      def initialize(request)
        self.request = request
      end

      # Accessor for the <tt>HTTPI::Request</tt>.
      attr_accessor :request

      # Executes the request and returns the response.
      def response
        @response ||= with_logging { HTTPI.get request }
      end

    private

      # Logs the HTTP request and yields to a given +block+.
      def with_logging
        Savon.log "----"
        Savon.log "WSDL request: #{request.url}"
        Savon.log "Using :#{request.auth.type} authentication" if request.auth?
        yield
      end

    end
  end
end

redpajama_set_name: RedPajamaGithub


We are just a few days away from the opening of eyephoneography #2, and as in eyephoneography #1 we want to have a mobile-photography community-fed instantly-curated slideshow accompanying the printed images of Carlein van der Beek, Matt Burrows, Stefano Giogli, and Jordi V Pou, during the opening day.
For this edition's slideshow we will open submissions on Friday (April 15th, 2011) at 18:00 GMT+1 until 15 minutes before the end of the event at 21:45 GMT+1.
The slideshow will be displayed on a screen in the EFTI gallery and will be curated on the fly by Paola Grilli and Laura Baffari of fotogriPhone.
FotogriPhone is the first italian blog dedicated to mobile photography shot and edited with the iPhone. Paola Grilli is an architect and Laura Baffari is a graphic designer. They are both passionate about photography and run several Flickr groups among which the very popular and tastefully curated Pic of the Day Award.
To have a chance to be selected for the slideshow, you will need to submit your images to the eyephoneography's Facebook page. Right now, submissions aren't possible but the page will accept them starting on Friday at 18:00 GMT+1. Please submit ONLY your own pictures and preferably no older that 2011.
If your image is selected and it is being shown in the gallery, fotogriPhone will post a comment on your photo to let you know.
For those of you that worry about photography rights on Facebook, you may want to know that they aren't very different from the ones of Tumblr or Posterous, and that anyway, for your peace of mind, you can always remove your photos from the page once the opening finishes.
How do I submit a photo here for your upcoming slideshow?
Hi Jeff. Right now you don't see anything because the posting is disabled. Friday at 18.00 GMT+1 we will open the wall to photo submissions and you will be able to post/submit your photos on this page's wall as you do on your own wall.
what does the +1 represent?
Linda, GMT+1 is Spain time zone.
Mario, we made some tests yesterday and the app worked. No email because the stream must be visible.


Gaza could have been a model of the future Palestinian state.
Gaza could have been a model of the future Palestinian state. Instead, it is a place of repression and aggression.
The deaths of Palestinian Arabs in Gaza, and of Israelis (Muslim and Christian Arab, and Druse and Bedouin, as well as Jewish, don't forget, in Ashdod and Sderot), are hardly ennobled by the sordid realization that the timing of the carnage has been determined by three sets of electoral calculation.
The first and the most obvious is the interregnum between U.S. presidencies, in which only the faintest of squeaks will be heard from our political class as our weapons are used to establish later bridgeheads and to realign our uneasy simultaneous patronage of the Israeli and the Egyptian and the Palestinian establishments. Benny Morris, one of the most tough-minded Israeli intellectual commentators, used to speculate that Israel would employ the Bush-Obama transition to strike at Iranian nuclear sites. He may have been wrong in the short term, but, in fact, the current attack on Gaza and Hamas is the same war in a micro or proxy form.
The third consideration, and the least noticed, is the fact that this month is the one where new elections for the Palestinian Authority have to be called by President Mahmoud Abbas, if not actually held. Before the new year, I talked to one or two knowledgeable Palestinians who argued that, under then-present conditions, Hamas had to hope that such elections would not soon take place. Life in Islamic Gaza was not such as to induce ecstatic happiness and prosperity among the populace: In common with many fundamentalist movements, the Muslim Brotherhood in its local Palestinian incarnation had badly overplayed its hand. It seems improbable that we'll ever know what would have happened in a free vote, but I think it's safe to say that recent events have further postponed the emergence of a democratic and secular alternative among the Palestinians. I even think it's possible that some people in Israel and some other people in Gaza do not want to see the emergence of such a force, but let me not be cynical.
Confronted with this amazing concatenation of circumstances, and with some of the frightening blunders—such as the last invasion of Lebanon—that have resulted from it, some Israeli politicians appear to think that taking a tough line in Gaza might at least be good for short-term morale. This was the clear implication of the usually admirable Ethan Bronner's New York Times front-page reports on Dec. 28, 2008, and Jan. 4, 2009. So why not just come right out with it and say that one is bombing for votes?
It is only when one begins to grasp all the foregoing that one understands exactly how disgusting and squalid is the behavior of the Hamas gang. It knows very well that sanctions are injuring every Palestinian citizen, but—just like Saddam Hussein's regime in Iraq—it declines to cease the indiscriminate violence and the racist and religious demagogy that led to the sanctions in the first place. Palestine is a common home for several religious and national groups, but Hamas dogmatically insists that the whole territory is instead an exclusively Muslim part of a future Islamic empire. At a time when democratic and reformist trends are observable in the region, from Lebanon to the Gulf, Hamas' leadership is physically and economically a part of the clientele of two of the area's worst dictatorships. (Should you ever be in need of a free laugh, look up those Western "intellectuals" who believe that a vote for an Islamist party and an Islamic state is a way to vote against corruption! They have not lately studied Iran and Saudi Arabia.) Gaza could have been a prefiguration of a future self-determined Palestinian state. Instead, it has been hijacked by the Muslim Brotherhood and made into a place of repression for its inhabitants and aggression for its neighbors. Once again, the Party of God has the whip hand. To read Benny Morris is to be quite able—and quite free—to doubt that there should ever have been an Israeli state to begin with. But to see Hamas at work is to resolve that whatever replaces or follows Zionism, it must not be the wasteland of Islamic theocracy.


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Funko Pop! Hip-Hop and R&B Figures: A Complete Guide
Dave Lifton
Dave Lifton Published: August 26, 2018
Since 1998, Funko has been been selling officially licensed collectible figurines of pop culture stars with their Pop! line. We're looking at the times they've created versions of hip-hop and R&B stars in the gallery below.
As of now, their selection for hip-hop and R&B musicians consists of figures for Notorious B.I.G., Tupac Shakur, Public Enemy, Run-D.M.C., Michael Jackson and Prince. But they make up for the lack of quantity with a very strong eye for detail in capturing some of their most iconic looks.
Tupac's red bandana is in its place around his head, as is his "Thug Life" tattoo across his torso. Biggie is resplendently decked out in his cream-colored suit, wide-brimmed hat and cane, and there's also a limited-edition metallic one. Chuck D has his red Public Enemy baseball cap on, and Flavor Flav has the giant clock around his neck. And, of course, Run-D.M.C. are wearing their Adidas.
Jackson has been represented five times, with looks made famous in the "Billie Jean," "Beat It," "Bad" and "Smooth Criminal" videos, and also the shiny military jacket that he wore to the 1984 Grammys, complete with only one glove.
And they're frequently adding more names to their collection. They unveiled three figurines of Prince in August 2018, using outfits and guitars used by him in Purple Rain, the "Raspberry Beret" video and the 3rdeyegirl era. As much as we'd like to see it, we're not going to hold our breath for them to recreate his infamous outfit from the1991 MTV Video Music Awards.
In addition to musicians, including classic rockers, the Pop! series also has figurines for athletes, movie and television characters -- real and animated, superheroes and video games. You can check them all out at their website.
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Source: Funko Pop! Hip-Hop and R&B Figures: A Complete Guide
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redpajama_set_name: RedPajamaCommonCrawl


text:
The Slaughter is the debut studio album by the American groove metal band Incite. It was released in 2009 on I Scream Music.

Track listing
 "Intro" - 0:57
 "The Slaughter" - 3:00
 "Nothing to Fear" - 3:31
 "Army of Darkness" - 2:24
 "Time for a Change" - 3:45
 "Divided We Fail" - 3:16
 "Rage" - 3:56
 "Tyranny's End" - 3:52
 "Die with What You've Done" - 2:42
 "Down and Out" - 3:00
 "End Result" - 2:49
 "Awakening" - 4:05
 "Absence" - 2:58 (Japanese edition bonus track)

Personnel
 Richie Cavalera - vocals
 Luis Marrufo - bass
 Zak Sofaly - drums
 Kevin "Dis" McAllister - guitars

External links
 Allmusic

2009 debut albums
Incite albums
Albums produced by Logan Mader

redpajama_set_name: RedPajamaWikipedia


Sensory play allows children to gain a relationship with the different sensations they will experience in their day-to-day life, and gives them the tools they need to engage with these stimuli in a positive way. There are all sorts of sensory toys available that can excite, soothe and teach your child, and the use of these toys in the right way can be a powerful tool for social connection and learning. Read on to learn about our Sensory Toys for Christmas 2018!
Buying presents at Christmas doesn't have to be a painful task. Here at Health and Care we have a growing range of products that can educate, entertain, comfort and make your life easier – all perfect for a Christmas gift. Grandparents can be difficult to buy for, so we have selected the top products that we believe make the Best Christmas Gift for Grandparents.


text:
El te bord (Chenopodium ambrosioides L.) és una planta herbàcia anual o perennant, de la família de les Quenopodiàcies. A Catalunya també es diu te fals, te d'Espanya, té de Mèxic, herba formiguera i herba dels leprosos i hi és considerada com invasora. És una planta utilitzada a Amèrica Llatina a causa de les seves propietats curatives per les seves propietats vermífugues i estomacals.

Morfologia

Chenopodium ambrosioides és una planta herbàcia, anual, camèfita (es troba a prop o dins del sòl) i teròfita (només hi ha llavors en les estacions adverses). Normalment oscil·la entre els 50 i els 60 centímetres d'alçada; encara que, en algunes ocasions, pot arribar al metre. El seu tall és erecte, estriat i molt ramificat sobretot a la seva base. És una planta pubescent, tant les fulles, com les flors i els fruits presenten uns pèls glandulars on es forma el seu actiu principal, l'oli essencial.

Fulles
Les seves fulles són nombroses, alternes i de color verd fosc vermelloses; les inferiors tenen generalment el limbe lanceolat-el·líptic amb les vores dentades o profundament sinuoses, les superiors són més petites, també lanceolades i amb les vores senceres. Mesuren de 5 a 8 cm de llarg i d'1 a 3 cm d'ample. Tenen el pecíol curt verd clar i nervadura pennada. Les fulles (sobretot aquelles que formen la sumitat florida) tenen un sabor aromàtic pel contingut d'essències, que poden augmentar segons el tipus de terreny i de clima on es trobi la planta.

Òrgans reproductors
Les flors, molt petites i actinomorfes, d'un mil·límetre apareixen entre juliol i setembre i presenten periant amb cinc sèpals. S'agrupen en una inflorescència racemosa que creix des de la unió entre les fulles i la tija de la part superior de la planta, on es poden distingir flors hermafrodites i femenines; aquestes últimes, només presenten gineceu mentre que les hermafrodites presenten androceu amb uns quatre estams a més de gineceu.

De la fecundació es forma un calze fructífer pentagonal, de 0,8 mm de diàmetre on es forma un fruit petit aqueniforme (de 0,7 mm de diàmetre) de forma arrodonida i color negre. Quan aquest fruit està encara recobert per la coberta floral, posseeix a la seva part més externa unes formacions amb un gran cúmul d'olis, que s'utilitzen per a la destil·lació i l'obtenció de la seva essència.

Distribució
Aquesta planta és originària d'Amèrica, es troba especialment a Mèxic i al sud-oest dels Estats Units. Encara que també la trobem a Europa, Àsia meridional, Àfrica i Austràlia on estan totalment naturalitzades. Als Països Catalans es localitza sobretot a les províncies d'Alacant, Barcelona, Castelló, Girona, Illes Balears (únicament a Eivissa, Formentera, Mallorca, Menorca), Lleida, Tarragona i València. Viu principalment a llocs humits, jardins, vores de camins i camps de cultius.

Nomenclatura
Chenopodium ambrosioides del grec chenos, d'oca i pous, peu, anomenat així per la forma de les seves fulles amb tres lòbuls que recorden al peu d'una oca. Ambrosioides, prové del grec Ἀμβροσία, α (a) prefix de negació i βρότος (brótos), mortal, el que mitològicament és un aliment reservat exclusivament als déus de l'Olimp. També és coneguda com a Epazote (del náhuatl epazōtl, epatli = guineu + zotli = herba) o paico (del quechua payqu) és una planta amb moltes utilitzacions medicinals. Depenent del lloc es coneix amb diferents noms científics: Ambrina ambrosioides (L.), Chenopodium anthelminticum (L.), Chenopodium integrifolium, Chenopodium obovatum., Chenopodium retusum, Dysphania ambrosioides (L.), Teloxys ambrosioides (L.) Teloxys vagans.

Cultiu
Es cultiva al llarg de l'any, preferentment en dies poc assolellats en sòls no inundables a manera d'hortalissa. Es recomana deixar entre planta i planta un espai de 0,25 m a 0,30 m, adobar quinze dies abans del cultiu definitiu i realitzar podes de formació. La seva propagació es pot fer mitjançant llavors sexuals i per divisió d'esqueixos. Les llavors tarden 10 dies a germinar. Es pot sembrar directament o per trasplantament al terreny definitiu quan les plantes tenen 20 dies i hagin assolit els 10 o 12 cm.

A part de la seva utilització en el camp de la medicina, l'epazote també s'utilitza en alimentació. Les seves fulles es consumeixen com a verdura en sopes, com l'anomenat "caldo verde" i el "chupe de paico". Les seves llavors s'utilitzen com a condiment a la preparació de "frijoles".

Per la conservació de la planta les parts vegetals, després del cultiu, han d'assecar-se a l'ombra. La seva comercialització pot ser en fresc, deshidratada o polvoritzada, empaquetada a pes, en fundes de te, polietilè, en flascons o tubs.

Farmacologia
Les infusions i decoccions de les fulles, arrels i inflorescències de C. ambrosioides s'han utilitzat durant segles de manera tradicional per diverses poblacions natives d'Amèrica Llatina i el Carib com a condiment i en medicina ètnica. A més a més, durant les primeres dècades del s. XX, l'oli essencial de C. ambrosioides era un dels antihelmíntics més utilitzats en humans, gossos, gats, cavalls i porcs. El seu ús va decaure a la dècada del 1940 al descobrir altres antihelmíntics menys tòxics. Es creu que a Europa va ser introduïda l'any 1577 per Francisco Hernández, que va ser també metge de Felip II d'Espanya. D'ell prové la primera menció al Vell món que es coneix sobre l'eepazotl, i d'on també es nombren per primer cop les virtuts medicinals que ja li atribuïen els natius de Mèxic.

Part utilitzada (droga)
S'empra la planta sencera especialment les tiges, les fulles i les llavors, d'on s'extreu l'oli essencial de l'epazote esmentat anteriorment. L'oli d'epazote està format principalment per ascaridol (60-80%) i altres compostos hidrocarbonats com el p-cimè, l'l-limonè, el d-alcanfor, etc.

Ús farmacològic i altres propietats
L'ascaridol ha estat utilitzat com antihelmíntic en el control de nematodes. Produeix un efecte paralitzant i narcòtic sobre els paràsits intestinals, fent que es desprenguin del teixit intestinal on es troben adherits.

A més a més, el paico té propietats antisèptiques, contraceptives, digestives, diürètiques, hepatoprotectores, acidesa, diabetis, dismenorrea, diarrea, flatulència, reumatisme a més d'altres.

Toxicitat

L'ascaridol extret directament de la planta i posteriorment purificat, posseeix una alta toxicitat, per tant, el seu ús va ser prohibit en alguns països des de fa anys. D'altra banda quan s'utilitza el paico que conté ascaridol sense purificar, la seva acció queda contrarestada amb els altres component que conté la planta, neutralitzant-se la seva acció tòxica. Tot i això, no existeix una dosi segura establerta i tant la forma d'ús com la quantitat emprada varia molt segons la regió, la seguretat i efectivitat no estan garantides per aquest motiu. Així, és aconsellable evitar prendre epazote en períodes d'embaràs i lactància i no s'ha d'administrar te o oli d'epazote a nens petits, ja que s'han donat alguns casos d'intoxicació en alguns països d'Amèrica Llatina on és més freqüent el consum d'aquesta planta. S'ha d'evitar també el seu consum en persones que pateixen úlceres, gastritis, problemes de fetge, malalties coronàries o mal funcionament dels ronyons.

Vegeu també
 Llista de plantes de fulla comestible

Bibliografia

Referències

Enllaços externs

Plantes medicinals cariofil·lals
Chenopodium